San Luis Dermatology & Laser Clinic, Inc.
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- Dinah Eustacia Wade
- 6 years ago
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1 San Luis Dermatology & Laser Clinic, Inc. Patient Name: Pharmacy Name: Primary Care physician: LOCATION City: Health History Intake Form The federal government has defined a complete electronic medical record (EMR) or electronic health record (EHR) as containing four basic functions: computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes. In 2009, as a part of the Economic Stimulus, the federal government began offering incentives to providers to encourage implementation of electronic health records. Providers must attest to demonstrating meaningful use every year to avoid payment adjustment. Providers have to show that they are meaningfully using their EHRs by meeting thresholds for a number of objectives. As part of the objectives we are asked to have our patients complete medical history questions, and demographics so that we may eventually qualify for meaningful use. Thank you for your cooperation in completing this information. Past Medical History: (please all that apply) Anxiety Arthritis Asthma Atrial fibrillation BPH Bone Marrow Transplantation Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis Hypertension HIV/AIDS Hypercholesterolemia Hyperthyroidism Hypothyroidism Leukemia Lung Cancer Lymphoma Pacemaker Prostate Cancer Radiation Treatment Seizures Stroke Valve Replacement Other Reviewed by: MPH RJH CBF JWD Date: Initials Page 1 of 5
2 Past Surgical History: (please all that apply) Appendix Removed(Appendectomy) Bladder Removed (Cystectomy) Mastectomy ( Right Left Both) Lumpectomy ( Right Left Both) Breast Biopsy( Right Left Both) Breast Reduction Breast Implants Colectomy: Colon Cancer Resection Colectomy: Diverticulitis Colectomy: IBD Gallbladder Removed Coronary Artery Bypass Percutaneous transluminal coronary angioplasty (ptca) Mechanical Valve Replacement Biological Valve Replacement Heart Transplant Joint Replacement Knee ( Right Left Both) Joint Replacement Hip ( Right Left Both) Kidney Biopsy Kidney Removed (Nephrectomy) (Right, Left) Kidney Stone Removal Kidney Transplant Ovaries Removed: Endometriosis Ovaries Removed: Cyst Ovaries Removed: Ovarian Cancer Prostate Removed: Prostate Cancer Prostate Biopsy TURP Skin Biopsy Basal Cell Cancer Surgery Squamous Cell Carcinoma Surgery Melanoma Surgery Spleen Removed (splenectomy) Testicles Removed (Right, Left, Both) Uterus (Hysterectomy): Fibroids Uterus (Hysterectomy): Uterine Cancer Other Skin Disease History: (please all that apply) Acne Actinic Keratoses Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer Other Do you wear Sunscreen? Yes No SPF: Do you tan in a tanning salon? Yes No Page 2 of 5
3 Family History: Do you have a family history of Skin Cancer? Basal Cell Carcinoma Yes No Squamous Cell Carcinoma Yes No Do you have a family history of Melanoma? Yes No Mother Father Sister Brother Daughter Son Uncle Aunt Nephew Niece Grandmother Grandfather Grandson Granddaughter Other Medications: (Please enter all current medications, or attach legible list) *Include Strength and dosage* Example - Aspirin 81mg tablets 1 daily Allergies to Medications: (Please enter all drug allergies & reactions (i.e. rash) Alergies: Alergies: Reactions Reactions ALERTS: (please Yes/No for the following) Alerts: Yes No Allergy to adhesive Allergy to lidocaine Allergy to topical antibiotic ointments Artificial heart valve Artificial joints within past two years Blood thinners Defibrillator MRSA Pacemaker Premedication prior to procedure Rapid heartbeat with epinephrine Pregnancy or planning a pregnancy History of blood transfusions Page 3 of 5
4 Social History: (please all that apply) Smoking Status: Never smoked Quit: former smoker Smokes less than daily Smokes daily Illicit Drug Use: Drug Use IV Drug Use Alcohol Use (ETOH) Safety: Birth Place: Alcohol: none Alcohol: less than 1 drink a day Alcohol 1-2 drinks a day Alcohol: 3 or more drinks a day I feel safe at home. I do not feel safe at home. City State Country Other Quality Measures For patients 65 and older: Vaccination Status: Have you received a pneumonia vaccination? Yes No Advance Care Do you have a health care proxy in the event you are unable to make your own medical decisions? Yes No Do you have a living will: Yes No Page 4 of 5
5 Review of Systems: Are you currently experiencing any of the following? (Please Yes/No for the following) Symptom Yes No Problem with bleeding Problems with healing Problems with scarring(hypertrophic or keloid) Rash Immunosuppression Hay fever Chest pain Fever or chills Night sweats Unintentional weight loss Thyroid problems Sore throat Blurry vision Abdominal pain Bloody stool Bloody urine Joint aches Muscle Weakness Neck stiffness Headaches Seizures Cough Shortness of breath Wheezing Anxiety Depression Other Symptoms: My Primary Care Physician is aware of my current Alerts & Symptoms Yes No PATIENT SIGNATURE Date: Thank you! Page 5 of 5
Preferred Pharmacy. Past Medical History
Name: Date: Street Address: City / State: Zip Code: Date of Birth: Gender: Phone Number (day): Phone Number (evening): Email Address: Emergency Contact: Preferred Pharmacy Name: Phone Number: City and
More informationCYNTHIA B. YALOWITZ, M.D., F.A.A.D.
Adult and Pediatric Dermatology Cosmetic Dermatology 3 NORTH AVENUE PHONE: (914) 833-3030, FAX (914) 833-3034 PAST MEDICAL HISTORY PLEASE CIRCLE ALL THAT APPLY. Select any of the following medical conditions
More informationNAME DATE Page 1. Other. Kidney Removed (Right, Left) Bladder Removed. Ovaries Removed for Endometriosis Breast Biopsy
NAME DATE Page 1 Past Medical History: (please circle ALL that apply) Anxiety Hepatitis Arthritis Hypertension Artificial joints HIV/AIDS Asthma Hypercholesterolemia Atrial fibrillation Hyperthyroidism
More informationTO SERVE YOU MORE EFFICIENTLY, PLEASE COMPLETE THIS FORM AND RETURN IT TO THE FRONT DESK BEFORE YOU ARE CALLED TO AN EXAM ROOM. THANK YOU.
NEW PATIENT FORM TO SERVE YOU MORE EFFICIENTLY, PLEASE COMPLETE THIS FORM AND RETURN IT TO THE FRONT DESK BEFORE YOU ARE CALLED TO AN EXAM ROOM. THANK YOU. DATE: ACCOUNT NUMBER: AGE: NAME: DATE OF BIRTH:
More informationMichael J. Huether, M.D., P.C. Arizona Skin Cancer Surgery Center, P.C. History and Intake Form. Patient Name D.O.
Past Medical History: (please mark the medical conditions that you currently have) Anxiety Arthritis Asthma Atrial Fibrillation Bone Marrow Transplant BPH Breast Cancer Colon Cancer COPD Coronary Artery
More informationIntake and History Form
Name: Date: Street Address: City / State: Zip Code: Date of Birth: Gender: Soc. Sec. #: Phone Number (day): Phone Number (day): Email Address: Emergency Contact: # Preferred Language: _ Race: Ethnic Group:
More informationPatient Last Name First Name Middle Name. Home Address City State Zip. Date of Birth Age Social Security # - - Cell Phone Home Phone Work Phone
Date Patient Last Name First Name Middle Name Gender (circle): Male Female Other: Marital Status (circle): Single Married Divorced Widowed Separated Home Address City State Zip Date of Birth Age Social
More informationPATIENT INFORMATION. Name: First Name MI Last Name. Date of Birth: / / Sex: Male / Female / Declined SSN:
PATIENT INFORMATION Name: First Name MI Last Name Date of Birth: / / Sex: Male / Female / Declined SSN: Race: Ethnicity: Hispanic/Latino Not Hispanic/Latino Declined Marital Status: Single Married Divorced/Separated
More informationNOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT We are concerned with your privacy rights. We are complying with national guidelines (HIPAA) to safeguard your personal health information. We keep a record
More informationPatient or Parent/ Guardian Signature Date
Today s Date Appointment Date Last Name First Name Middle Initial Birthdate Age Title: (circle one) Mr. Mrs. Dr. Ms. Miss Sex: (circle one) M F Home Phone Cell Work Email Primary Insurance ID number Subscriber
More informationPatient Registration Form
Patient Registration Form Patient's Last Name: Patient's First Name: MI: Address: City, State, Zip Code: Patient's Date of Birth: Patient's Social Security: Best Number to Contact: Secondary Number: Marital
More informationIs there any person (including your spouse) that you would like medical information released to? If so please give the following information:
(PLEASE PRINT) Date: Patient Information: Home Phone: Cell Phone: Name: Last Name First Name M.I. Mailing Address: City: State: Zip: Birth Sex: M F Age: Birth date: Status: Married Widowed Single Separated
More informationTitle: Dr/Mr/Mrs/Ms/Miss Last First M.I. Circle one. Primary Address: Street # Street name Apt# City State Zip
Elissa S. Norton, MD 5162 Linton Blvd, Suite 203 P: (561) 877-3376 F: (877) 992-1153 info@brilliantdermatology.com Name: Title: Dr/Mr/Mrs/Ms/Miss Last First M.I. Circle one Primary Address: Street # Street
More informationDate: PATIENT INFORMATION Name SS# LAST FIRST MIDDLE INITIAL. Date of Birth Gender Male Female Marital Status Single Married Divorced Widowed
Date: PATIENT INFORMATION Name SS# LAST FIRST MIDDLE INITIAL Date of Birth Gender Male Female Marital Status Single Married Divorced Widowed Address Alternate Address STREET CITY STATE ZIP STREET CITY
More informationIntake and History Form
Name: Street Address: City / State: Zip Code: Date of Birth: Gender: Marital Status: Single Married Divorced Widowed Preferred Language: Race: Ethnicity (Hispanic/Latino): Yes No Email Address: Home Number
More informationPATIENT REGISTRATION (Please Print)
14800 W. Mountain View Blvd., Suite 160 13090 N. 94 th Drive, Suite 101 Surprise, AZ 85374 Peoria, AZ 85381 (623) 584-3376 (623) 584-3376 Fax: (623) 584-3375 Fax: (623) 584-3375 PATIENT REGISTRATION (Please
More informationF M S M W D. Age Birth Date Gender Marital Status Cell Phone
MIDWEST DERMATOLOGY CLINIC, PC Patient Legal Name Last First Middle Initial Today s Date Mailing Address Street City and State Zip Home Telephone F M S M W D. Age Birth Date Gender Marital Status Cell
More informationPharmacy and Referrals Pharmacy Name, Street Address & Telephone #: Primary Care Physician s Name, Location & Telephone #:
Patient Registration Please Print Clearly Date: Last Name: First Name: Middle Initial: Sex: Date of Birth: / / Age: Social Security: - - Address: City: State: Zip Code - Circle Preferred Phone Number Home
More informationIf you have any questions about this payment method, do not hesitate to ask. Visa MasterCard American Express Discover Other:
To Our Patients: As you know if you have ever checked into a hotel or rental car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage
More informationPharmacy and Referrals Pharmacy Name, Street Address & Telephone #: Primary Care Physician s Name, Location & Telephone #:
Patient Registration Please Print Clearly Date: Last Name: First Name: Middle Initial: Sex: Date of Birth: / / Age: Social Security: - - Address: City: State: Zip Code - Home Phone #: Work Phone #: Cell
More informationDERMATOLOGY AND COSMETIC MEDICINE SPECIALISTS Jay D. GeIler, MD FAAD FASD FASDS Deborah Petrowsky, MD Elizabeth Walsh, PA-C
310 Route 24 East (Chester Commons) Chester NJ, 07930 (908) 879-8800 Fax (908) 879-2955 DERMATOLOGY AND COSMETIC MEDICINE SPECIALISTS Jay D. GeIler, MD FAAD FASD FASDS Deborah Petrowsky, MD Elizabeth Walsh,
More informationConsent to Treat, Medical Release of Information Notice, and Agreement to Pay Notice. Date of Birth:
Marnie Ririe, MD, FAAD Tiffany McCray, PA-C 1636 Hadley Ave. Boise, ID 83709 Phone: (208) 258-2078 FAX: (208) 258-2079 Consent to Treat, Medical Release of Information Notice, and Agreement to Pay Notice
More informationPATIENT INFORMATION. RESPONSIBLE PARTY (If Different from Patient) POLICY HOLDER INFORMATION (If Different from Patient)
PATIENT INFORMATION Today s Date: Patient s Last Name: First: M.I. Mailing Address: City: State: Zip: Home Phone: ( ) Cell: ( ) Work: ( ) Date of Birth: / / Age: Sex: SSN: Driver s License #: Marital Status:
More informationPATIENT NAME DATE. Wendy A. Epstein, M.D., F.A.A.D. Board Certified Dermatologist (Cellular Dr. Epstein)
VenoLase Laser Treatment Center Palisades Professional Center 2 Medical Park Drive West Nyack, New York 10994 845-358-8878 Rex Ghassemi, M.D. Donna Konlian, M.D.. Wendy A. Epstein, M.D., F.A.A.D. Board
More informationPatient Registration Form : PATIENT INFORMATION Name: Date of Birth: Sex: Street Address: City/State Zip Code:
For office use only: EMA Centricity Insurance Patient Registration Form : PATIENT INFORMATION Name: Date of Birth: Sex: Street Address: City/State Zip Code: Race: Ethnic Group: Preferred Language: Marital
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Dermatology-Dermatologic Surgery- Aesthetic and Cosmetic Dermatology Name: Preferred Name: Sex: M/F DOB: SS# : Marital Status: Primary Care Phy: Referred By: Street Address: City/State: Zip Code: Cell
More informationPatient Registration Form: PATIENT INFORMATION Name: Date of Birth: Sex: Street Address: City/State Zip Code:
For office use only: EMA Centricity Insurance Patient Registration Form: PATIENT INFORMATION Name: Date of Birth: Sex: Street Address: City/State Zip Code: Race: Ethnic Group: Preferred Language Marital
More informationName DOB Date. Past Surgical History
Name DOB Date Past Medical History Anxiety Coronary Artery Disease Hypercholesterolemia Arthritis Depression Hyperthryroidism Asthma Diabetes Hypothyroidism Atrial Fibrillation(Irregular Heartbeat) End
More informationHISTORY INTAKE FORM **CIRCLE ALL THAT APPLY ABOUT YOU**
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More informationThank you for selecting our practice. Please download all the attached forms, complete and bring them with you to your appointment.
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More informationPatient Registration Form: PATIENT INFORMATION Name: Date of Birth: Sex: Street Address: City/State Zip Code:
For office use only: EMA Centricity Insurance Patient Registration Form: PATIENT INFORMATION Name: Date of Birth: Sex: Street Address: City/State Zip Code: Race: Ethnic Group: Preferred Language Marital
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3350 Highway 138 West w Wall, NJ 07719 1004-G Commons Way w Toms River, NJ 08753 Telephone w 732-280-1200 Telephone w 732-349-6868 Fax w 732-280-1207 Fax w 732-349-6022 Please complete this form to ensure
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Dermatology Medical History Patient: Date of Birth: _/_/ Today's Date: _!_!_ Reason fo r today's visit:---------------------- ------ Past Medical History: (please circle all that apply) Anxiety Arthritis
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